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Genitourinary trauma

Last updated: March 5, 2021

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Genitourinary trauma involves injury to the kidneys, ureters, bladder, and/or urethra. It may result in high morbidity if not properly identified and managed. The diagnosis of genitourinary trauma typically relies on patient history, physical examination, urinalysis, and imaging (CT, cystoscopy, retrograde urethrogram). Renal trauma is most often an acute condition caused by a blunt abdominal injury and may, if severe, represent a urological emergency. The classical symptoms of renal trauma are hematuria and pain in the affected side following injury. Mild trauma generally only requires monitoring, while high-grade injury may require emergency surgery and intensive care. Injury to the ureters is rare and generally iatrogenic, occurring mostly during operative procedures. Management may require stent placement with surgical repair. Bladder injuries are common in blunt abdominal trauma. Classic symptoms are gross hematuria, an inability to void, and abdominal pain. Extraperitoneal bladder injuries usually resolve with catheterization, while intraperitoneal injury requires surgery, which can help to prevent peritonitis and urosepsis. Urethral injuries may involve the posterior urethra, causing a high-riding prostate and blood at the urethral meatus, or the anterior urethra, causing perineal pain or hematoma. Treatment may be conservative or surgical depending on the severity of injury. Complications of the genitourinary tract include urinary extravasation, urinoma, abscess formation, renal hypertension, and loss of function in the affected kidney.

Renal and ureteral injuries [1][2]

  • Blunt abdominal trauma (80% of cases); : falls from a height, automobile collisions, blows to the torso; , pelvic fractures
  • Blunt thoracic trauma: associated with lower rib (9th –12th) fractures
  • Penetrating trauma (gunshot or stab wounds)
  • Assault (physical or sexual)

Bladder injuries

Urethral injuries [3][4]

  • Almost exclusively seen in men
  • Less common in women due to a shorter and more mobile urethra
  • Anterior urethral injuries
  • Posterior urethral injuries: significant pelvic fracture due to trauma (e.g., a vehicle collision): bulbomembranous junction is commonly injured

In patients with pelvic fractures, always evaluate for possible injury to the genitourinary system.

Renal and ureteral injuries [5]

Bladder injuries

Urethral injuries

Anterior urethral injury Posterior urethral injury
Findings upon examination
  • High-riding prostate on exam
  • Inability to void despite urge palpable distended bladder
  • Suprapubic pain
Urine extravasation

Injury to the urinary system can be easily masked by multiple concurrent injuries to other organ systems and is therefore easily overlooked.

General approach to genitourinary trauma [6]

Evaluate the genitourinary tract in a retrograde fashion, beginning with the external genitalia and urethra.

Renal and ureteral injury

  • CT with IV contrast of the abdomen/pelvis: to assess renal and accompanying injuries or intra-abdominal fluid retention
  • Delayed CT imaging: indicated if injury to the renal pelvis and ureters is suspected
  • IV pyelography: to assess for contrast extravasation if delayed CT images are nondiagnostic
  • Urethrocystography: if CT is unavailable

Bladder injury

Urethral injury

  • Retrograde urethrogram: to rule out suspected urethral injury
    • First diagnostic step (before catheterization) in a patient with suspected urethral injury
    • Findings: contrast extravasation from the urethra at point of injury
  • Foley catheter placement
    • Suspected urethral injury is a relative contraindication for catheterization, as it may worsen the injury.
    • In cases of gross hematuria without other clinical signs of urethral injury, a single attempt at Foley catheter placement may be performed.
    • Successful catheterization without resistance makes urethral injury an unlikely diagnosis.
    • If any resistance is met, retrograde urethrography should be performed.

The absence of hematuria in urinalysis does not exclude renal injury because not all injuries affect the renal pelvis.

General

  • Hemodynamically stable patients with minor trauma: observe with Foley catheter placement, if needed, for hematuria and/or oliguria
  • Hemodynamically unstable patients: may require immediate surgical intervention for other injuries prior to definitive treatment of genitourinary injuries

Renal and ureteral trauma [7][8]

Low-grade renal injury

High-grade renal injury

Ureteral trauma

Bladder injuries

Urethral injuries

We list the most important complications. The selection is not exhaustive.

  1. Salam MA. Principles & Practice of Urology. Universal-Publishers ; 2003
  2. Crandall J, Kent R, Patrie J, Fertile J, Martin P. Rib fracture patterns and radiologic detection--a restraint-based comparison.. Annu Proc Assoc Adv Automot Med. 2000; 44 : p.235-59.
  3. Ryan S, McNicholas M, Eustace SJ. Anatomy for Diagnostic Imaging. Elsevier Health Sciences ; 2011
  4. Sırmalı M. A comprehensive analysis of traumatic rib fractures: morbidity, mortality and management. Eur J Cardiothorac Surg. 2003; 24 (1): p.133-138. doi: 10.1016/s1010-7940(03)00256-2 . | Open in Read by QxMD
  5. Hematuria. http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/nephrology/evaluation-of-hematuria/. Updated: January 1, 2009. Accessed: March 6, 2017.
  6. Saunders F, Argall J. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Investigating microscopic haematuria in blunt abdominal trauma. Emerg Med J. 2002; 19 (4): p.322-323.
  7. Mingoli A, La Torre M, Migliori E, et al. Operative and nonoperative management for renal trauma: comparison of outcomes. A systematic review and meta-analysis. Ther Clin Risk Manag. 2017; 13 : p.1127-1138. doi: 10.2147/tcrm.s139194 . | Open in Read by QxMD
  8. Brandes S, Coburn M, Armenakas N, McAninch J. Diagnosis and management of ureteric injury: an evidence-based analysis. BJU Int. 2004; 94 (3): p.277-289. doi: 10.1111/j.1464-410x.2004.04978.x . | Open in Read by QxMD